ATI RN
ATI nur330 Med Surg Exam Questions
Extract:
Question 1 of 5
A nurse is caring for a client in a critical care unit who suffered a knife wound to the chest. The nurse suspects the client is developing cardiac tamponade. Which of the following assessment findings should the nurse identify as supporting this suspicion?
Correct Answer: A
Rationale: Muffled heart sounds are a hallmark finding in cardiac tamponade due to fluid accumulation in the pericardial sac, which dampens the sound of the heart. Flattened neck veins are inconsistent with cardiac tamponade; distended neck veins are commonly seen. Tachycardia, not bradycardia, is a compensatory response. Lethargy is not specific to cardiac tamponade.
Question 2 of 5
A sexual assault nurse examiner (SANE) is a caring for a client who experienced sexual assault. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: The SANE's priority is to ensure the client's safety and well-being. Legal testimony, police involvement, and evidence collection are secondary or not the nurse's role.
Question 3 of 5
A nurse is conducting a primary survey of a client who has sustained life-threatening injuries due to a motor-vehicle crash. Identify the sequence of actions the nurse should take.
Correct Answer: C,D,E,B,A
Rationale: The ABCDE framework prioritizes airway (jaw-thrust), breathing (ventilatory assessment), circulation (IV access), disability (Glasgow Coma Scale), and exposure (remove clothing).
Question 4 of 5
A nurse is caring for a child who is having a seizure. Which of the following actions should the nurse take?
Correct Answer: A,C,D
Rationale: Side-lying position prevents aspiration, removing objects reduces injury risk, and assessing airway patency prevents hypoxia.
Tongue depressors and restraints are contraindicated.
Question 5 of 5
A nurse is providing care for a client diagnosed with diabetic ketoacidosis (DKA). Which of the following characteristics are associated with DKA?
Correct Answer: C,E,F
Rationale: DKA is characterized by metabolic acidosis, hyperglycemia (>250 mg/dL), and ketosis due to fat breakdown. It causes dehydration, not fluid overload, and is associated with high, not low, blood sugar.